Provider Demographics
NPI:1346233780
Name:GOBERVILLE, GARY E (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
Last Name:GOBERVILLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:E
Other - Last Name:GOBERVILLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2344 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5122
Mailing Address - Country:US
Mailing Address - Phone:954-344-3937
Mailing Address - Fax:954-344-2434
Practice Address - Street 1:2344 N. UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-5126
Practice Address - Country:US
Practice Address - Phone:954-344-3937
Practice Address - Fax:954-344-2434
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2575152WP0200X, 152WS0006X, 152WV0400X
FLOPC2575152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078957700Medicaid
FL078957700Medicaid
FL20377Medicare PIN